Key Factors for Creating a Residency Track in Global Health

Dr. Bearman Teaching a Medicine Resident in La Hicaca, Honduras

This is a great article forwarded to me by my pediatric colleague Dr. Pat Mason. This is a study by Campagna et al that surveyed global health education directors at 24 pediatric residencies regarding factors deemed essential to creating global health programs; their response rate was 79% (19 programs). The key factors for creating a dedicated global health tract were: having support of key program and department leadership, resident commitment, protected resident elective time, faculty having protected time/ support and having a dedicated program budget; one of the other key elements outlined was having administrative support. The authors conclude that all of these things should be considered when creating a residency-based global health program. This article provides a nice "roadmap" for educators designing global health programs within residencies.

What is Global Health?

What is Global Health? I give a lecture on global health to second year medical students and always struggle to define this-the definition ends up being a sort of 'catch all' term to describe anything relevant to health that does not respect political boundaries.

Rowson and colleagues explore the evolution of the "global health" concept and definition in their article "Conceptualising global health: theoretical issues and their relevance for teaching" (full text can be found here). They discuss the discipline's roots within 19th century "international health," a construct that largely focused on protecting European and North American infection control and colonial interests. The field evolved in the 20th century to address major public health menaces such as malaria and smallpox, and later became more comprehensive including public health policy, a broader focus on economics as well as other factors.

Rowson and colleagues cite my favorite modern definition of the field: Koplan et al defined global health as: "an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care."

Rowson and his colleagues do not provide a suggestion for a new definition, however, they discuss definition features that are still being debated. Specifically, they note 3 key things:

1) The "object of knowledge" associated with the field (what topics are covered? what is the scope of coverage?)
2) The "types of knowledge" associated with practitioners in the field
3) The "purpose of knowledge" within the field

Rowson et al argue that any definition of global health should avoid the inclusion of value-laden terms such as "equity." They note that inclusion of values in the definition implies that people who do not ascribe to the defined value are not practicing or studying global health. Although this argument is sound and academically "true," I still prefer the aforementioned Koplan definition that emphasizes health equity.

The article by Rowson and colleagues is an excellent overview of how the field of global health has evolved and what it encompasses; moreover, it succinctly highlights the key features that are still being actively debated.

Ethical Issues in Global Health Outreach Work: A Call for Formalized Medical Student Education

VCU Medical Students Assessing a Patient in Coyoles, Honduras

This is an interesting article published earlier this year by Timothy Lahey in the journal Academic Medicine. In this perspective piece Lahey discusses some of the ethical issues associated with short-term global health outreach work, especially as faced by medical students. He outlines the key components of a medical school curriculum in global health, noting this is important for all learners as "global rightly includes local because healing the sick has the same worth in inner-city Detroit as it does on the outskirts of Dar es Salaam, even if geography and culture alter the manifestations of illness and need."

Lahey notes that the principles of biomedical research should can be applied to global health outreach work: nonmaleficence, beneficence, patient autonomy and justice. Short-term medical trips are rife with pitfalls in all of these areas, as providers often provide sub-standard care without understanding the health needs of the population they are serving, or the greater context of the health pressures faced by these communities or the health disparities that drive illness.

Lahey notes a medical curriculum for global health must include an exploration of health disparities, and notes that faculty mentorship and post-trip debriefing are important components of medical student education in global health.

Over the past 6 years working on short-term medical relief missions in Honduras I personally have struggled with many of the issues Lahey brings up, and have watched many medical students and residents struggle with these issues, as well. Our group has worked to address these issues via close community partnerships, an emphasis on high-yield public health interventions, and providing logistical support to help bolster the longitudinal health efforts of the local ministry of health (find out more about the evolution of our program here).

 In terms of working with students, we have found the following:

1) Pre-trip counseling/ education of learners is essential
2) Providing learners a context for their work (e.g., how their work contributes to the longitudinal/ overall health work performed by the group) is critical
3) Continuous 'checking in' with learners/ helping learners process their experience before, during and after the brigades is very important

As "global health" truly includes addressing health issues/ disparities both internationally and domestically, Lahey's call for integration of global health education into medical school curricula is an excellent one. This 'call' should be extended to residents' curricula, as well.